Onbedoelde schade in Nederlandse ziekenhuizen: dossieronderzoek van ziekenhuisopnames in 2004.

Ieder jaar lopen ongeveer 30.000 patiënten schade op tijdens de behandeling in het ziekenhuis, die voorkomen had kunnen worden. Zo blijkt uit het onderzoek dat op initiatief van de Orde van Medisch Specialisten door het EMGO Instituut/VUmc en het NIVEL is uitgevoerd. Een kostenpost van 167 miljoen euro (1 %) op de gezamenlijke ziekenhuisbudgetten. Het rapport ‘Onbedoelde schade in ziekenhuizen’ wordt vandaag gepresenteerd en overhandigd aan minister dr. A. Klink van Volksgezondheid, Welzijn en Sport. De Orde van Medisch Specialisten vindt elke vermijdbare schade er een te veel en zet daarom in op gerichte acties. Voor het eerst is in Nederland onderzoek gedaan naar onbedoelde en vermijdbare schade in de ziekenhuizen. Jaarlijks worden 1,3 miljoen mensen in het ziekenhuis opgenomen. Hiervan krijgt 5,7 % te maken met schade tijdens de behandeling. In minder dan 40% van de gevallen is de schade te voorkomen. De schade kan leiden tot tijdelijke of blijvende beperkingen, een verlengde opname of voortijdig overlijden. In het buitenland komt onbedoelde schade voor bij 2,9% tot 16,6% van de ziekenhuispatiënten. In het onderzoek is apart gekeken naar patiënten die in het ziekenhuis overlijden. Hieruit blijkt dat van de 42.000 patiënten (3% van de totale ziekenhuisopnames) die in het ziekenhuis overlijden dit bij 1735 patiënten waarschijnlijk voorkomen had kunnen worden. Openheid van zaken De belangrijkste vragen in het onderzoek waren: hoe vaak lopen patiënten onbedoeld schade op in het ziekenhuis? Hoe ernstig is die schade? En in hoeverre had die schade voorkomen kunnen worden? Het onderzoek is mogelijk geweest doordat 21 ziekenhuizen volledige openheid van zaken hebben gegeven. In totaal zijn 7926 dossiers van patiënten uit 2004 beoordeeld en geanalyseerd. Uit het onderzoek blijkt dat de oorzaken, naast menselijke factoren, moeten worden gezocht in organisatorische en technische zaken. In een vervolgonderzoek dat in het voorjaar van 2008 wordt afgerond, wordt nader ingegaan op de oorzaken. Gerichte acties De Orde van Medisch Specialisten heeft veel respect voor de ziekenhuizen, verpleegkundigen en medisch specialisten die aan dit onderzoek hebben meegewerkt. Over de uitkomsten van het onderzoek heeft de Orde een duidelijk oordeel: elk vermijdbaar overlijden of schade is er een te veel. Naast vermijdbare schade kan er ook schade ontstaan die is toe te schrijven aan complicaties of risico’s van de behandeling zelf. Dat is niet te voorkomen. Met de uitkomsten van het onderzoek wil de Orde samen met de NVZ vereniging van ziekenhuizen, de Nederlandse Patiënten Consumenten Federatie, Nederlandse Federatie van Universitair medische centra en Verpleegkundigen & Verzorgenden Nederland op 12 juni 2007 een gericht actieplan presenteren

Huisartsen met en zonder elektronisch medisch dossier: weinig verschil in medisch handelen.

De representativiteit is onderzocht van de gegevens over huisartsgeneeskundige zorg uit huisartspraktijken die deelnemen aan geautomatiseerde registratienetwerken en intensief gebruikmaken van het elektronisch medisch dossier (EMD). Vraagstelling: Zijn er verschillen in huisartsgeneeskundig handelen tussen huisartsen die intensief, weinig of niet gebruikmaken van het EMD? Methode: Door secundaire analyses zijn verschillende aspecten vergeleken van het huisartsgeneeskundig handelen (voorschrijf-, verwijsgedrag, preventief handelen, kwaliteit van praktijkvoering) tussen groepen huisartsen die in verschillende mate gebruikmaken van het EMD. Resultaten: De gevonden verschillen tussen EMD-gebruikers en minder intensieve of niet-EMD-gebruikers in voorschrijf- en verwijsgedrag zijn klein. Wat betreft de betrokkenheid bij preventie zijn geen verschillen tussen huisartsen naar de mate van EMD-gebruik gevonden. De verschillen op items met betrekking tot de kwaliteit van de praktijkvoering tussen de huisartsen uit het registratienetwerk en de referentiegroep zijn, op één subonderwerp na (de discrepantie tussen feitelijke en gewenste werkdruk), niet statistisch significant. Conclusie: De vermeende geringe representativiteit van gegevens over huisartsgeneeskundige zorg van huisartsen die deelnemen aan registratienetwerken heeft weinig empirische grond.(aut. ref.

Variation in adverse event incidence rates between hospitals and hospital departments. The Dutch adverse events study.

Objective: To assess the variation in adverse event (AE) rates at the hospital and hospital department level, in order to gain insight in room for improvement of patient safety at each level. Methods: Randomly selected records of 7926 hospital admissions of 2004 from 4 university and 17 general hospitals were reviewed by trained nurses and physicians between August 2005 and October 2006. The physicians identified AEs, degree of preventability, most responsible medical specialty and causes of AEs, and patient and admission characteristics. Additional patient information, including coded discharge diagnoses (ICD-9), Charlson comorbidity index and coded interventions, was received from the Dutch registration of hospital information. We applied multivariable logistic multilevel analysis (MLwiN version 2.02), using AE incidence rates in university and general hospitals as an outcome, to apportion variance to hospital and hospital department level while correcting for differences in patient mix (age, sex, admission urgency, surgical or non-surgical admission, diagnostic group and comorbidity). Covariates were entered stepwise into the model and were centred to reference values for all Dutch hospital admissions. Results: The unadjusted AE incidence rates were higher in university hospitals (8.2, 95%CI 6.8 to 9.9) than in general hospitals (5.1, 95%CI 4.5 to 5.9). After adjusting for patient mix, this difference was no longer statistically significant (6.2, 95%CI 4.0-9.3 versus 3.7, 95%CI 2.9 to 4.7). The adjusted incidence of AEs per hospital ranged from 2.0% to 6.5%. Preventable AEs occurred less often in university hospitals (1.5, 95%CI 1.0 to 2.2) than in general hospitals (2.2, 95%CI 1.8 to 2.8), but this difference was not statistically significant and further adjustment for patient mix slightly decreased the estimated incidence rates. The adjusted incidence of preventable AEs per hospital ranged from 0.9% to 2.7%. When apportioning variance in the incidence of AEs, without additional correction for patient mix, differences between hospital departments had more impact (intraclass correlation (ICC) 10.3%) than differences between hospitals (ICC 3.4%). After correction for age, sex and admission urgency, the ICC for hospital departments decreased to 8.3%, and after further correction for admission to surgical or non-surgical department, diagnostic group and comorbidity to 5.9% while the ICC for hospital variation stayed stable. Age, admission urgency, surgical admission, and comorbidity showed a statistically significant association with the incidence of AEs. Increasing age, more comorbidity and admissions to surgical departments were associated with more AEs; whereas urgent admission was associated with less adverse events compared to planned admissions. Since patients are often treated by different medical specialties, the admission department not always reflects the specialty responsible for the AEs. Especially, in patients admitted to non-surgical departments 13 to 19% of AEs occur under responsibility of surgical specialities. In patients admitted to surgical departments, 98 to 100% of AEs are caused by surgical specialties. Limiting the analyses to surgical patients alone did not materially change the results and showed larger variance at the hospital department level compared to the hospital level. Discussion: In university hospitals more AEs but not more preventable AEs occurred than in general hospitals. When apportioning variance in incidence of AEs to hospitals and hospital departments, differences between hospital departments had more impact than differences between hospitals. Thus, when improving patient safety we should focus on unsafe hospital departments rather than on unsafe hospitals. (aut. ref.

Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review

Objective: This study determined the incidence, type, nature, preventability and impact of adverse events (AEs) among hospitalised patients and potentially preventable deaths in Dutch hospitals. Methods: Using a three-stage retrospective record review process, trained nurses and doctors reviewed 7926 admissions: 3983 admissions of deceased hospital patients and 3943 admissions of discharged patients in 2004, in a random sample of 21 hospitals in the Netherlands (4 university, 6 tertiary teaching and 11 general hospitals). A large sample of deceased patients was included to determine the occurrence of potentially preventable deaths in hospitals more precisely. Results: One or more AEs were found in 5.7% (95% CI 5.1% to 6.4%) of all admissions and a preventable AE in 2.3% (95% CI 1.9% to 2.7%). Of all AEs, 12.8% resulted in permanent disability or contributed to death. The proportion of AEs and their impact increased with age. More than 50% of the AEs were related to surgical procedures. Among deceased hospital patients, 10.7% (95% CI 9.8% to 11.7%) had experienced an AE. Preventable AEs that contributed to death occurred in 4.1% (95% CI 3.5% to 4.8%) of all hospital deaths. Extrapolating to a national level, between 1482 and 2032 potentially preventable deaths occurred in Dutch hospitals in 2004. Conclusions: The incidence of AEs, preventable AEs and potentially preventable deaths in the Netherlands is substantial and needs to be reduced. Patient safety efforts should focus on surgical procedures and older patients.

Nature, occurrence and consequences of medication-related adverse events during hospitalization: a retrospective chart review in the Netherlands.

BACKGROUND: Medication-related adverse events (MRAEs) form a large proportion of all adverse events in hospitalized patients and are associated with considerable preventable harm. Detailed information on harm related to drugs administered during hospitalization is scarce. Knowledge of the nature and preventability of MRAEs is needed to prioritize and improve medication-related patient safety. OBJECTIVE: To provide information on the nature, consequences and preventability of MRAEs occurring during hospitalization in the Netherlands. STUDY DESIGN: Analysis of MRAEs identified in a retrospective chart review of patients hospitalized during 2004. METHODS: The records of 7889 patients admitted to 21 hospitals in 2004 were reviewed by trained nurses and physicians using a three-stage process. For each hospital, patient records of 200 discharged and 200 deceased patients were randomly selected and reviewed. For each patient record, characteristics of the patient and the admission were collected. After identification of an MRAE the physician reviewers determined the type, severity, preventability, drug category and excess length of stay associated with the MRAE. Data on additional interventions or procedures related to MRAEs were obtained by linking our data to the national hospital registration database. The excess length of stay and the additional medical procedures were multiplied by unit costs to estimate the total excess direct medical costs associated with the MRAE. RESULTS: In total, 148 MRAEs occurred in 140 hospital admissions. The incidence of MRAEs was 0.9% (95% CI 0.7, 1.2) and the incidence of preventable MRAEs was 0.2% (95% CI 0.1, 0.4) per hospital admission. The majority of non-preventable MRAEs were adverse drug reactions caused by cancer chemotherapy. Preventable MRAEs were most often found in relation to anticoagulant treatment administered in combination with NSAIDs. Both non-preventable and preventable MRAEs resulted in considerable excess length of hospital stay and costs. On average, MRAEs resulted in an excess length of stay of 6.2 days (95% CI 3.6, 8.8) and average additional costs of &U20AC;2507 (95% CI 1520, 3773). CONCLUSIONS: This study was the first to provide detailed information on MRAEs during hospital admissions in the Netherlands, which were associated with both considerable patient harm and additional medical costs. To increase patient safety, interventions need to be developed that reduce the burden of MRAEs. These interventions should target the areas with the highest risk of MRAEs, notably antibacterials, cancer treatment, anticoagulant treatment and drug therapy in elderly patients.(aut. ref.

Do Mothers Matter? A Comparison of Models of the Influence of Mothers' and Fathers' Educational and Occupational Status on Children's Educational Attainment

families, historical trends, social inequality, status attainment,